HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 112 ABBOTT STREET 3/30/2026 Comn-ionwealttl of Massachusetts Town Of North Andover
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DEP has provided this form for use by local Boards of Health, Ot 11 a e
nfo(rnalion musk be subslanhally the sarne as Ihat provided here. Before using Phis for , cFia k with your
local Board of Health to determine the fornl they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days frorn 'he pumping date in
accordance with 310 C M R 15.351. - - --------�
HOUSE front<-Tack
a )side re r lr r
A, Facility Inforr-nation SUILDING front side rear, left r
Important:When
F)ECK: under
on the compWo(, 3 ItJ 1:flllln oul forms 1 s(ef_0 L o Z
uSe only the tab y
key to rove your Address
cursor-do not v A
use the velum ._._- �_ _ __" r _ .._--
key chy/Town Slate Zip Code
(J( �. IS,y -tent tDwner
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Narne
Address (It diffe(ont f(orn locallon)
MA
T-. pt�i — -- —
ele ,ne t umber
B, Purnping Record
1. Date of Pumping " _ -__ -----.___ 2. Quantity Pumped'. _-
�a1i� Galivns
3. Cornponent ❑ Cesspool(s) Z71111S e ptic."rank ❑ -fight Tank
g ❑ Grease Trap
L___} Other (d es s c r I b e) _.. ._. ._ . ._.._ _.__..
4. Effluent Tee Filter presenl? EJ ','es o� If yes, was it cleaned? ❑ 'Yes No
5. Observed condition of corrrponer f) ( lped�
C (NF9�_�Fr
l F�<) npeerJ By
11vey -- _.._.._._- Mass 1AAOSE Ma s 1AD31Z
_ on 'nlcacpfises, Inc.
C�3rn a n y
1 l.oc Iion wile f ,onterrts (c disposed
GLSD
____. __
ignalure o t-tauter Data _._.._.
-------- —
S I n a t u r o p( R e cce iv I n c f<a c i I i t __-----------._-----._
9 J Y for �Uuch facility rer,cipt) Date
7
l5lornikdoc, 11112 Syslern Pumping Record . PagEJ 1 C7f q